A nurse is caring for a client who is receiving 0.9% sodium chloride solution to treat dehydration. Which of the following findings should the identify as an adverse effect of the infusion?
Increased bowel sounds
Dark amber urine
Shortness of breath
Decreased skin turgor
The Correct Answer is C
A. Increased bowel sounds: Increased bowel sounds are not associated with IV fluid therapy. They typically occur with gastrointestinal stimulation or diarrhea, not with excessive fluid administration.
B. Dark amber urine: Dark urine indicates concentrated urine and dehydration, suggesting that the client may still be underhydrated rather than experiencing an adverse effect of fluid infusion.
C. Shortness of breath: Shortness of breath can indicate fluid volume overload, an adverse effect of rapid or excessive infusion of 0.9% sodium chloride. The fluid may accumulate in the lungs, leading to pulmonary edema and impaired gas exchange.
D. Decreased skin turgor: Decreased skin turgor is a sign of dehydration, which should improve—not worsen—during IV fluid therapy. Its presence would suggest inadequate fluid replacement rather than an adverse effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","H"]
Explanation
- +1 nonpitting edema noted to feet and ankles: The reduction from +3 pitting edema to +1 nonpitting edema indicates improved fluid status and decreased venous congestion, reflecting effective management of heart failure symptoms.
- Client reports shortness of air improved and only occurs with significant exertion: Dyspnea with minimal activity has improved to only occurring with significant exertion, suggesting enhanced cardiac output and better pulmonary perfusion.
- Client states has more energy: Increased energy demonstrates improved tissue perfusion and oxygen delivery, indicating stabilization of heart failure symptoms.
- Client states is sleeping better: Better sleep reflects decreased nocturnal dyspnea and improved overall cardiac function.
- Weight decreased from 82.1 kg (181 lb) to 78.9 kg (174 lb): Weight loss in a client with heart failure indicates effective diuresis, reduced fluid retention, and improved volume status.
Correct Answer is D
Explanation
A. "I should check the client's gastric residual prior to initiating TPN.": Gastric residual monitoring applies to enteral nutrition, not parenteral. TPN bypasses the gastrointestinal tract entirely, so gastric residual checks are unnecessary.
B. "Clients who require long-term nutritional support are prescribed TPN.": Long-term nutrition is often managed with enteral feeding when possible. TPN is reserved for clients who cannot use their GI tract due to conditions like bowel obstruction or severe malabsorption.
C. "I should administer TPN intravenously over 6 hr.": TPN is infused continuously over 24 hours using an infusion pump to maintain stable glucose levels and prevent complications such as hypoglycemia or osmotic diuresis. A 6-hour infusion is unsafe.
D. "TPN is administered for clients who are unable to absorb nutrients from their intestinal tract.": This statement is accurate. TPN provides essential nutrients intravenously for clients with nonfunctional or severely impaired GI tracts, ensuring adequate nutrition and metabolic support.
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